The glucose error in arterial sampling: assessing staff awareness and the effect of sampling technique*

Abstract

Background Using a dextrose-containing solution, instead of normal saline, to maintain the patency of an arterial cannula results in the admixture of glucose in line samples. This can misguide the clinician down an inappropriate treatment pathway for hyperglycaemia. Methods Following a near-miss and subsequent educational and training efforts at our institution, we conducted two simulations: (1) to observe whether 20 staff would identify a 5% dextrose/0.9% saline flush solution as the cause for a patient’s refractory hyperglycaemia, and (2) to compare different arterial line sampling techniques for glucose contamination. Results (1) Only 2/20 participants identified the incorrect dextrose-containing flush solution, with the remainder choosing to escalate insulin therapy to levels likely to risk fatality, and (2) glucose contamination occurred regardless of sampling technique. Conclusion Despite national guidance and local educational efforts, this is still an under-recognised error. Operator-focussed preventative strategies have not been effective and an engineered solution is needed.

Dextrose-Containing Infusion Running in An Arterial Line System

“…The role of continuing education of staff members responsible for the management of patients using arterial line systems towards preventing the never-event under discussion remains paramount. Reference [8] published the outcome of a simulation of awareness of the critical care staff members to erroneous blood glucose reading resulting from a patient having an arterial line system with dextrose infusion running as a flush fluid. The simulation was done on the background of previous occurrence of iatrogenic hypoglycaemia caused by treating spurious hyperglycaemia resulting from using dextrose solution to maintain arterial line cannulation and the education of their staff members to this danger had prior been done.…”